Homeowners Insurance Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

* Last Name

* First Name

Street Address

City

State

Zip Code

Phone Number

Alternate Telephone

Fax Number

Social Security Number

Birth Date

* Email Address

Property Information

Property Street Address

City

State

Zip Code

Dwelling Type

Number of Bedrooms

Number of Bathrooms

Number of Fireplaces

How many porches or decks are there?

What year was it built?

What date was the property purchased?

What is the construction type?

How many stories is it?

If two stories, what is the ground floor square footage?

Total square footage

What is the property's topography?

What foundation type?

If structure is located in a flood zone, what is the distance to body of water?

Garage Description

What type of roof covering?

Was the roof updated?

Yes

No

If yes, what year?

Does the building have a pool?

Yes

No

If yes, is it fenced?

Yes

No

If there is a pool, is there a diving board?

Yes

No

If there is a pool, is there a slide?

Yes

No

What is the distance to fire protection?

Is the building in the brush?

Yes

No

Is there a brush hazard within one mile of the building?

Yes

No

If yes, has the brush been cleared by 250 feet from all sides of the building?

Yes

No

Is there a smoke alarm?

Yes

No

Is there a fire extinguisher?

Yes

No

Are there deadbolts?

Yes

No

Is the electrical updated?

Yes

No

Are there circuit breakers?

Yes

No

Does the electrical circuit box have copper wiring?

Yes

No

How old is the heating/ air conditioning?

Is the heating / air conditioning thermostatically controlled?

Yes

No

What is the energy source?

What is the heating system?

What is the cooling system?

Has the plumbing been updated?

Yes

No

Is the plumbing copper?

Yes

No

Does the building have interior automatic fire sprinklers?

Yes

No

Is there a theft alarm?

Yes

No

What is the earthquake zone?

Has it been earthquake retroffited?

What is the fire district?

Are there dogs on the property?

Yes

No

If yes, how many and what is the breed of each dog?

Are there any other pets or animals on the property?

Yes

No

If yes, how many and what is the description of each?

Current Coverage Information

Current Insurance Company

Expiration Date

Were there any losses or claims in the last 5 years?

Yes

No

If yes, what is the date, amount paid and description of each loss or claim?

Desired Coverage Information

Dwelling Amount - Coverage A

Other Structures - Coverage B

Personal Property - Coverage C

Loss of Use - Coverage D

Premise Liability - Coverage E

Policy Deductible

If earthquake insurance is requested, select deductible percentage %

Do you want building replacement cost coverage?

Yes

No

Do you want contents replacement cost coverage?

Yes

No

Questions or Comments

Best Time To Contact You

Please let us know the best time to call and discuss your quote.

Morning

Afternoon

Evening

Anytime

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